Couples Center of the Pioneer Valley
Please answer the following questions so we can provide you with an available appointment based on your insurance, availability, and preferences. You will receive an email with information on what to expect from our center upon the form submission.
Please make sure to check spam folder for emails from intake@pioneervalleycouplestherapy.com
Basic Information
If you decide to move forward with therapy, we'll need the following information to create an account for you inside our therapy portal.
What best describes what you're looking for?
Couples Therapy
Individual Therapy
Discernment Sessions
Intensives
What's your full legal name?
*
What's your date of birth?
*
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Month
-
Day
Year
Date
What's the best number for us to call?
*
Format: (000) 000-0000.
What's your email address?
*
example@example.com
What's your partner's full legal name?
What's your partner's date of birth?
-
Month
-
Day
Year
Date
What's your partner's email?
example@example.com
Unless agreed upon by your clinician, sessions will be on the same day and time every week. Specify available days and times available. Please consider couples sessions average 75 minutes.
You will be offered a standard date and time for your ongoing treatment on a weekly basis.
Are you at the brink of separation or divorce?
*
Yes
No
Tell us about your relationship structure...
In a few lines, how can we help you in your current situation?
Do you have concerns about either your own or your partners substance or alcohol use? Please explain.
Is there a history of violence or interpersonal violence in your relationship? If so, please explain.
Are you currently having issues with an affair, infidelity or a history with cheating, lying, etc.?
Are you concerned about any untreated important mental health issues (eg Major Depression, Anxiety Disorder, Bipolar, etc) with either you or your partner? Please explain.
Is there an additional partner you'd like to include at this time?
Yes
No
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Insurance
If using insurance, we ask you to provide your insurance information on this form so that we can run your benefits and notify you how much your insurance is going to cover and if there is any deductible that needs to be met.
{name}, will you be using your insurance?
*
Yes
No
{name}, please provide your current insurance information below.
*
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Specialized Services
Please note that our specialized services below are not covered by insurance.
Would you be open to a consultation call from a licensed therapist to learn more about our specialized services? This includes discernment counseling, rapid access appointments, intensives, and mini-intensives which are not covered by insurance.
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Yes
No
Which of the following would you like to learn more about?
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Discernment Counseling (2 hours)
Rapid Access Appointment (2 hours)
Mini-Intensive (4 hours)
Couples Intensive (1 or 2 day)
Trauma Intensive for Individuals
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